When Patients Discontinue Care

By John Amaro, LAc, DC, Dipl. Ac.(NCCAOM), Dipl.Med.Ac.(IAMA)

Calling for my attention, my front-office manager stated, "Mrs. Smith has cancelled her upcoming appointments because she said the treatment gave her a headache." This is one of the most disheartening, frustrating scenarios any health care practitioner can experience. It is one that every practitioner has dealt with. However, the practitioner who ends up with the least number of these situations over a career is the undisputed winner. Every LAc, MD, DC, ND, DO and any other practitioner reading this article can relate to this situation, as it has happened to everyone.

Upon reviewing Mrs. Smith's file, I was reminded of the reason she was coming to my clinic in the first place, which was because of chronic, disabling headaches that occurred a minimum of five times per week for nearly two years. The fact that she called to cancel her appointment because she suffered a headache following the second treatment is disturbing to me and frustrating to the extreme; especially when one considers the fact that she entered my office with a "raging" headache, only to have it relieved in excess of 80 percent (by her admission) following the first treatment. Why in the world would she think or feel my treatment gave her a headache, when her medical history without specific treatments is filled with daily headaches?

Within 30 minutes of the Mrs. Smith situation, my office staff advised me that a very prominent person who has the connections to refer a number of patients to my office, had cancelled her future appointments. This person, who is now 42 years old and a medical professional, has experienced chronic constipation since she was a child. To the best of her recollection, she has been suffering since she was seven or eight years old. She is unable to move her bowels without the aid of an enema and cannot recall having a natural urge to evacuate or a time where she moved her bowels without some artificial aid.

Following her first treatment, she reported having "miraculous" results to the acupuncture and ionic minerals I had prescribed. While in the examining room with a patient the following day she suddenly was taken with the overwhelming urge to run to the bathroom to have what she described as a "major evacuation." She was elated with the response, even though she was a bit concerned that she would be interrupted in her medical practice with such a strong healing response when she least expected it.

Following the patient's second treatment, the response was not quite as dramatic, but still present. Following the third treatment, she contacted the office to advise us she would not be returning because the treatments were not helping her following the second treatment. She had received three treatments for a lifelong problem, experienced major clinical response, yet cancelled future treatments on the premise that the treatments were not working. To say I was frustrated would be a gross understatement.

Were either one of those scenarios anything I could have avoided? Can I eliminate those frustrating days from happening in the future? I suppose the answer is "no," I could not have academically or practically prevented either one of those situations; and unfortunately, there is nothing I can do to prevent future encounters of this kind with other patients.

I have always felt it was imperative to give a patient a general guideline as to what can be expected from treatment, and the basic number of times a person with their problem would be expected to visit the office. Not only do I verbally give a patient my recommendations as to the number of treatments which would be expected for their condition, but I also give them a letter to take home that, among other things, states they may on occasion feel a general worsening of symptoms as the body goes through a very accelerated healing response with acupuncture. Even though most patients will experience a relief of symptoms quickly, some will, unfortunately, feel increased paraesthesia, soreness and healing response following the early treatments.

In most conditions that I see clinically, I recommend 12 treatments as a trial of therapy. I am specific that I would much rather give them three treatments than 12; however, they cannot enter treatment with the thought that they will take three treatments to see how it will work. That's kind of like a surgeon telling a patient they must have a three-hour operation, and the patient stating, "Well, I'll try an hour and a half to see how I do." Unless a patient is committed to receiving 12 treatments, it is best they not even start. However, there is nothing better than to be able to tell a patient we can go on PRN (as needed) treatments after only a few visits.

It has been my experience that the vast majority of patients with various conditions respond very well within 12 visits, with most having major response within the first three to six visits. However, there are a few patients who are minimally improved, or not at all, at the end of 12 treatments. At this point, a decision must be made to go forth or to realize the treatments are not going to be effective with the current plan of attack.

Was it the patient's severe condition and the inability to respond, or is it the practitioner's approach? I have always said that I do not believe acupuncture ever fails; I believe the acupuncturist does. On the other hand, we have a tendency to say the patient has reached maximum medical improvement.

Patient education is the key to a well-informed and cooperative patient. If anything will eliminate patients from discontinuing treatment prematurely, it is due to whatever effort we put into the early encounters to help them understand what to expect and not get frustrated if response is not as quick as they wish to see.

With the general public's fascination and reliance on allopathic medication many, if not most, patients feel that the object is to take a pill and experience instant response. They feel this is what they should expect in the acupuncturist's office as well. However, if the medication was as powerful and as healing as one would think, they would only have to put one pill in the bottle instead of 50 to be taken three times a day.

Regardless of how much education you provide the patient or what kind of incredible clinical response you will achieve quickly, we are all going to have patients discontinue care for a variety of meaningless and seemingly ridiculous reasons. I guess the best thing we can do is to realize we are all in very good company. The number one lesson to be learned here is to focus on the positive many as opposed to the negative few. Do not let these situations bring you down.

As I speak to acupuncturists around the world, I am constantly asked about how to deal with this situation. It is very real, it is very common and it is as you know very frustrating. Just try to put your focus on the current patients who truly need your help and never lose site of the incredible healing consciousness we have been given.

May you have one of the most successful years in your career as we enter into 2009. All the best for your success.

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